ET 2611 AGE: 7+ INSEAM: (Front Rider) 16"–30"

W E C A N C U S T O M B U I L D B A S E D O N Y O U R S P E C I F I C N E E D S !

PROPULSION

ET 2611 (Jan 19/16)

PAGE SUB-TOTAL

E. Total Length: 101"F. Width: 38"G. Steering head tube

unlocks/locks steering

• Frame Height: 17” • Driver’s Seat Height: 29”+ (STD)(Modified frame for smaller inseams)• Front Rider Seat easily slides back and forth as well adjusts up and down; Minimum Seat Height: 22”

F*Maximum Weight on Removable Rear Platform is 25 lbs.

FRAME CHOICE

DRIVER INFORMATION (2) Male Female

#1 Driver’s Name: _________________________________________________

Weight: _______lbs. _______kgs. Height: _______inches _______cm

#2 Driver’s Name: _________________________________________________

Weight: _______lbs. _______kgs. Height: _______inches _______cm

G1

E

2

BOTTOM BRACKET WIDTH

Standard Crank 6" Wide (std)

A

C D

B

RIDER INFORMATION (1) Male Female

Rider’s Name: ____________________________________________________

Date of Birth: MONTH ____________ /DAY ____________ /YEAR ___________

Diagnosis: ________________________________________________________

Weight: _______lbs. _______kgs. Height: _______inches _______cm

A. Seat Depth: ________ inches ___________ cm

B. *INSEAM: ________ inches ___________ cm

C. Back Height: ________ inches ___________ cm

D. Seat Width: ________ inches ___________ cm

THERAPIST’S Name: ______________________________________________

Phone: ___________________________________________________________

Fax: ____________________________________________________________

Email: ___________________________________________________________

NEW

NEW

Tilt seats may be limited degrees because of driver steering

COLOR CHOICE

Please note extra delivery time for non-standard & custom colors.

WHEELS

P QON

FORK

Suspension Fork (std)

TIRES

P. Smooth (n/a)

Q. Knobby (std)

Shorter range is suitable for limited knee flexion.

I. 3" (79mm) x 26T Alloy Crank (n/c)

CRANK ARM LENGTHS - RANGE OF MOTION

I J K L

ET 2611 (Includes std Bold Items) $5,764.70Custom Frame (call for price)

Removable Rear Platform (Required for Electrical Assist) $368.15

Seat Post Length (Option Required): 28-38” inseam (STD) 33-41” inseam Second Seat & Post ($129.66)* (*For multiple Drivers whose inseams do not fall into the same inseam range.) Offset Seat Post ($65.05)

Candy Blue Hot Rod Purple (std)

Blue Red Yellow Pink

Other Custom Color

Please Specify: ____________________

Sticker Type Male Female

8 Speed Nexus Shifter w/ twist grip (std) Shift Lever Location RIGHT Hand Control On/Off Reciprocator Shift Lever Location RIGHT LEFTElectric Assist

J. 4" (102mm) x 32T Alloy Crank (std)

k. 5” (127mm) x 32T Alloy Crank (n/c)

L. Crank Shortener (reduces length by 1/2”)

FOOT PLATFORM (When front rider’s inseam is less than 16”)

ABS Foot Platform

N. Aluminum (std)O. Spoke Covers (set of three)

Effective January 19, 2016 Page 1

CHAIN GUARD

Heavy Duty Steel Chain Guard (std)

W E C A N C U S T O M B U I L D B A S E D O N Y O U R S P E C I F I C N E E D S ! PAGE SUB-TOTAL

Creating a CYCLE of mobilityTM

BRAKE LEVER POSITIONLEVER POSITIONING FRONT BRAKE REAR BRAKE

Left Handlebar

Right Handlebar

BRAKE OPTIONS

FRONT RIDER SEAT BASE

1415

8 9 10 11 12 13 16

COMMENTS:

FRONT RIDER HANDLE BARS Steering: Locked

R. High Rise (n/c)

S. Hoop (std)

T. Wide (n/c)

R TS

i

N O T E : H e a d R e s t M a y R e s t r i c t S t e e r i n g / T u r n i n g R a d i u s

FRONT RIDER BACK REST

Chest Strap High Back only (std)17. Child Low Back - (13" width, 7.5" height) (std)

(Includes Custom Back) (2 Required for Set)

a. chesT WidTh ______ inches ______ cm b. seaT To aRmpiT ______ inches ______ cm

NEW

17

AB

19 18 20 21 22

FRONT RIDER HEAD REST

PLEASE NOTE: Required for addition of Adjustable Rain and Sun Shade Canopy

24. Adjustable Velcro Occiput Support Cushion PLEASE NOTE: Includes Adjustable/Removable Headrest option.

25. i2i Head & Neck Support System with Support Bracket PLEASE NOTE: Please specify size as per brochure.26. Headpod Support System with Support Bracket PLEASE NOTE: Includes Adjustable/Removable Headrest option.

Custom - Custom Mount of Head Support Bracket (Template required) (call for price)

heighT: ________ inches ________ cm WidTh: ________ inches ________ cm

Adjustable Rain & Sun Shade Canopy PLEASE NOTE: Requires the Adjustable/Removable Headrest

26252423

PEDALSMeasure Rider’s Shoe: i) _____ inches _____ cm ii) ______ inches ______ cm OR TRACE OUTLINE OF RIDER’S SHOE ON A PIECE OF PAPER & SUBMIT w/ORDER.

Please specify Left or Right

5 76

3 42

ii

i

Shoe Heel Widest Point

Shoe length

1

FRONT BRAKE REAR BRAKE

Vee Brakes (std) Disc Brakes (std)

Disc Brakes *Must have Suspension Fork (N/A with Electric Assist)

6. Pulley System (FRONT: corrects plantar flexion) Pulley System (REAR: self-leveling pedals) 7. Abductor Leg Brace *requires #5 Molded ABS Footplate S M L

1. Mountain Style Pedal (std) 2. with Cage ($42.65) 3. Neoprene Adjustable Footplate* S M L XL 4. Molded ABS Footplate System* XS S M L XL 5. Molded ABS Footplates with Ratcheting Straps Size Options: XS S M L XL

0.25” Footplate Spacers Qty: ______/Pedal ($13.66/uniT)

8. Child (12.5" width, 12.5" depth) (std)9. Child Narrow

10. Adult Seat (16.75" width, 14" depth)

11. Adult Narrow

12. Add 2" Raised Pommel to seat selection above

13. Custom (measurements) (call for price)

A. ________ inches ________ cm B. ________ inches ________ cm

14. Hip Belt, 1.5" wide (n/c)

15. Hip Belt, 2" wide M L (std)16. Neoprene Hip Stabilizer Belt

18. Child High Back - (13" width, 18" height) 19. Adult Low Back - (17" width, 10" height) 20. Adult High Back - (17" width, 18" height)

Recline back 21. TilT seaT 22. Lateral Support Bracket complete w/Track S L ($352.71/EA)

i. Nameplate Special Dedication ($42.65) Company Logo ($74.36)

23. Adjustable/Removable Headrest

Effective January 19, 2016 Page 2

Creating a CYCLE of mobilityTM

STATIONARY TRAINER

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Total - Page 2

Total - Page 1

SUB-TOTAL

TOTAL

ABDUCTOR/ADDUCTION

27 28

GLOVES

Hand Tracing RequiredB

A

A. Measure width of palm _____ inches _____ cm

B. Measure width of wrist _____ inches _____ cm

C. Measure bend of wrist to top of middle finger _____ inches _____ cm

C

PRIVACY POLICYFreedom Concepts Inc. collects, uses and discloses personal information of the Customer and/or Rider to properly assemble and manufacture the mobility deviceand may contact the Rider’s therapist for additional personal information to assistwith this process. The collection, use and disclosure of the personal informationof the Customer and/or the Rider is governed by any consent which may, from timeto time, be provided, and by the Freedom Concepts Inc. Privacy Policy which isavailable on our website www.freedomconcepts.com or by contacting our office.By signing below, you hereby warrant that you have the authority to bind the Riderand hereby authorize the collection, use, and disclosure of personal information asherein provided and in accordance with the Freedom Concepts Inc. Privacy Policy.

TERMS & CONDITIONSPrices are subject to change without notice. Prepaid or net 30 days O.A.C.All taxes extra. Freight extra. Manufacturer reserves the right to change prices,colors, features, dates, locations and products without notice. Residentialdelivery charge may apply. Duty and brokerage included where applicable.

SIGNATURE OF RIDER/PARENT

I hereby give permission to Freedom Concepts Inc. to use photographs of me or my child for the sole purpose of the company’s promotional use, and will not be distributed to third parties. YES NOI would like to receive regular updates. SNAIL MAIL EMAIL NO

CUSTOMER SIGNATURE

CUSTOMER INFORMATIONDealer/Vendor: ______________________________________________________

Contact Person: _____________________________________________________

Address: ___________________________________________________________

City: ________________________ Prov./State: ___________________________

Postal/Zip Code: _____________ Ordered by: ___________________________

Phone: ____________________________ Fax: ___________________________

Email: _____________________________________________________________

ORDER INFORMATIONPurchase Order: _____________________________________________________

Order Date: __________________________________ Quote Date: ____________

FCI Representative: __________________________________________________

Payment Terms: _____________________________________________________

CREDIT CARD (check one) Visa MasterCard Exp. Date: ___________

Card Number: _______________________________________ __________

Name On Card: _________________________________________________

Signature: ______________________________________________________

SHIPPING INSTRUCTIONS

Name: _____________________________________________________________

Address: ___________________________________________________________

City: _______________________________________________________________

Province/State: ______________________________________________________

Postal/Zip Code: ________________ Phone: ______________________________

Federal ID/SS#: ______________________________________________________

CHEST HARNESS

ACCESSORIES

Self Centering Spring Locking Hand Brake (std) Safety Flag Wheel Reflectors (std)

Neoprene Chest Harness - Medium

Neoprene Chest Harness - Large

Neoprene Chest Harness - Extra Large

X Small Small Medium Large

Custom (call for price)

Indoor Stationary Trainer

27. Abductor (Removable Leg Divider)

28. Padded Leg Adduction Strap

Freight (crated) ($300.00)

Residential Delivery

Tax 1

Tax 2

Other

Animal Squeaky Horn (n/c)Multitool (sold separately $16.00) (std)Bell (std)Tool Pouch Bike Covers Cane/Crutch Holder Oxygen Tank Holder (Specify Tank Size ________) iPad/Tablet Holder Communication Tray Simulated Sheepskin Seat Cover Child ($118.60) Adult ($132.78)

Effective January 19, 2016 Page 3